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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005308
Report Date: 09/17/2024
Date Signed: 09/17/2024 02:54:47 PM


Document Has Been Signed on 09/17/2024 02:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:CRYSTAL CARE HOMEFACILITY NUMBER:
306005308
ADMINISTRATOR:LAUGUICO, CRISTINAFACILITY TYPE:
740
ADDRESS:9391 TOUCAN AVETELEPHONE:
(714) 553-8674
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 3DATE:
09/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:51 PM
MET WITH:Cristina Lauguico - AdministratorTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPA was greeted at the facility by Cristina Lauguico, Administrator. LPA explained the purpose of the inspection.

The facility is one-story home with four resident bedrooms, two resident bathrooms, kitchen, dining room, living room, TV room, laundry room, attached 2-car garage and backyard. There are three rooms that are non-resident rooms. Staff reside in two of these rooms. AD's relative resides in the third non-resident room. This individual is not employed by the facility but is fingerprint cleared. Facility appears clean, safe and sanitary. LPA observed the facility has the necessary postings posted on the walls.


All resident rooms had the required elements, including bed, chair, closet space and ample lighting. Facility has extra linens and hygiene supplies for residents in hallway cabinets. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured between 105 and 120 degrees F. LPA observed facility has emergency food and water supply. LPA observed the fire extinguisher was purchased on 11/3/2023 according to the receipt attached to the extinguisher. Smoke/Carbon Monoxide detector was tested and noted as operational. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in the garage and laundry room. Knives are locked up separate from toxic chemicals. Medication for each resident is kept locked in a cabinet in the TV room. Exit gate is unlocked. LPA observed exit gate to be unobstructed. Based on record review, the facility does not have record of disaster drills conducted. A deficiency is being issued. LPA reviewed three resident files, three staff files and the criminal record clearance for the non-staff person who lives at the facility. LPA also reviewed medication for three residents. LPA interviewed one staff and one resident.

Based on today's inspection, one deficiency is being issued. An exit interview was conducted and a copy of this report and appeal rights were provided to the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/17/2024 02:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: CRYSTAL CARE HOME
FACILITY NUMBER: 306005308

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above due to the facility being unable to produce documentation of disaster drills conducte which poses a potential safety risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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Administrator stated they will conduct a drill, document it and send record of drill conducted to LPA via email by the assigned POC due date of 9/30/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
LIC809 (FAS) - (06/04)
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